局部解剖腹部3結(jié)腸下區(qū)、腹膜后隙

1、局部解剖學(xué),腹部的局部解剖與操作（3）,主要內(nèi)容 Main Content,The infracolic compartment 結(jié)腸下區(qū)The retroperitoneal space 腹膜后隙,一、結(jié)腸下區(qū)Infracolic Compartment,概述空腸 jejunum 回腸 ileum盲腸cecum闌尾 vermiform appendix結(jié)腸colon,,結(jié)腸下區(qū)位于橫結(jié)腸及其系膜與小骨

2、盆上口之間，主要有空腸、回腸、盲腸、闌尾、結(jié)腸及其的血管、淋巴和神經(jīng)等。,,,Appendix,（一）空腸與回腸Jejunum and Ileum,位置與形態(tài)結(jié)構(gòu) 腸系膜 mesentery血管 blood vessels淋巴lymph神經(jīng) nerves,（1）空腸占空回腸全長的近側(cè)2/5；回腸占遠(yuǎn)側(cè)3/5。（2）空腸位于左腰區(qū)和臍區(qū)；回腸位于臍區(qū)、右腹股溝區(qū)和盆腔內(nèi)。,1.位 置,空腸 回腸,,（2）回腸管徑較

3、細(xì)，管壁較薄，血管弓級數(shù)較多，呈粉灰色，粘膜皺襞疏而低，有集合淋巴濾泡。,（1）空腸管徑較粗，管壁較厚，血管弓級數(shù)較少，呈粉紅色，粘膜皺襞高而密。,2.形態(tài)結(jié)構(gòu),小腸的X線像（前后位）,jejunumileum,,（3）空腸血管弓級數(shù)為1～2級；（4）回腸血管弓級數(shù)為3 ～ 4級。,空、回腸的區(qū)別,,2. 腸系膜,Mesentery,,,,,腸系膜竇 mesenteric sinus左腸系膜竇 Left

4、mesenteric sinus右腸系膜竇Right mesenteric sinus,,,腸系膜根radix of mesentery,,3.空、回腸的動脈和靜脈,Antimesenteric border對 系 膜 緣,,Mesenteric border系 膜 緣,,Mesenteric triangle,,空、回腸的血管分布特點(diǎn)及臨床應(yīng)用,,,,,腸切除吻合術(shù)時腸系膜應(yīng)作扇形切除，且對系膜緣側(cè)的腸壁應(yīng)稍多切除一些，以

5、保證吻合口對系膜緣側(cè)有充足的血供，避免術(shù)后缺血壞死或愈合不良。,,,4.空、回腸的淋巴,5.空、回腸的神經(jīng),,（二） 盲腸 Cecum,位置毗鄰形態(tài)結(jié)構(gòu),盲腸的位置、毗鄰和動脈,,盲腸的形態(tài)結(jié)構(gòu),網(wǎng)膜帶,獨(dú)立帶,結(jié)腸帶,系膜帶,盲腸的形態(tài)結(jié)構(gòu),回盲瓣回盲口闌尾開口,（三） 闌尾 appendix,位 置體表投影形態(tài)結(jié)構(gòu)血 管國人闌尾常見位置及其炎癥時的臨床表現(xiàn),闌尾的位置、形態(tài)結(jié)構(gòu)和血管,,

6、,,,,,,,,,,,闌尾根部的體表投影：McBurney’s point is a point at the lateral third of the line joining umbilicus and right anterior superior iliac spines（在臍與右髂前上棘連線的中、外1/3交界處）, indicating the base of the descending appendix 。,臨床意義：診斷

7、闌尾炎時，確切的體表投影位置并不十分重要，有臨床價值的癥狀是轉(zhuǎn)移性右下腹疼痛，并在右下腹有一個局限性固定壓痛點(diǎn)則更具有診斷意義(問號上的一點(diǎn))。,內(nèi)1/3段,中1/3段,外1/3段,Lanz’s point is a point at the right third of the line joining the anterior superior iliac spines, indicating the tip of the desc

8、ending appendix.,,,,,,,,McBurney’s point,左1/3段,中1/3段,右1/3段,國 人 闌 尾 常 見 位 置,（28%）,（26%）,（24%）,（6%）,（8%）,闌尾常見位置及其炎癥時的臨床表現(xiàn),,（四） 結(jié)腸 colon,分部位置及毗鄰 血管,結(jié)腸的分部及形態(tài)特征,,,,,,,,,,,Features of colon,結(jié)腸帶 colic bands (mesocolic band,

9、omental band , free band)結(jié)腸袋 haustra腸脂垂 epiploic,Division,,Ascending colon,Descending colon,Right colic flexure,left colic flexure,Transverse colon,Sigmoid colon,結(jié)腸的動脈,,,,,,,,,,,,結(jié)腸的淋巴管和淋巴結(jié),（五） 肝門靜脈Hepatic Portal Vein

10、,組成類型行徑毗鄰屬支收集范圍,,肝門靜脈的組成,肝門靜脈的行徑和毗鄰,,肝門靜脈的屬支和收集范圍,,Cystic vein,,,,,,,,,,,腸系膜下靜脈匯入部位的類型,1,1,1,2,2,2,3,3,3,Ⅰ型52.0%,Ⅱ型13.3%,Ⅲ型34.7%,腸系膜上靜脈Superior mesenteric vein,2. 脾靜脈Splenic vein,3. 腸系膜下靜脈Inferior mesenteric vein

11、,3）肝門靜脈系與上、下腔靜脈系之間的交通途徑:①食管靜脈叢；②直腸靜脈叢；③臍周靜脈網(wǎng)；④椎靜脈叢。,門-腔吻合的臨床意義：①正常情況下，門-腔間的吻合支細(xì)小、血流量少。②當(dāng)肝門靜脈及其分支受壓迫，導(dǎo)致血液回流受阻時，肝門靜脈內(nèi)的血液將逆流，經(jīng)門-腔吻合回流至腔靜脈。由于門-腔吻合支血流量增多、血管增粗，致食管靜脈叢曲張、直腸靜脈叢曲張和臍周靜脈網(wǎng)擴(kuò)張，出現(xiàn)嘔血、便血和海蛇頭樣外觀。失代償時，收集區(qū)的器官淤血，出現(xiàn)脾腫大和腹

12、水等門脈高壓綜合征的表現(xiàn)。,,,,,,二、腹膜后隙 Retroperitoneal Space,基本概念腎 kidney輸尿管腹部 abdominal part of ureters腎上腺 suprarenal gland腹主動脈 abdominal aorta下腔靜脈 inferior vena cava腰交感干 lumbar sympathetic trunk,腹膜后隙retroperitoneal space：位于后

13、腹壁的壁腹膜與腹內(nèi)筋膜之間，上起自膈，下至骶骨岬，兩側(cè)向外連于腹膜下筋膜。,（一）基本概念,,,,,,,腹膜后間隙內(nèi)有腎上腺、腎、輸尿管、腹部大血管、神經(jīng)和淋巴結(jié)等器官結(jié)構(gòu)以及大量疏松結(jié)締組織。,（二）腎 Kidney,位置與毗鄰 position & relations腎門、腎竇和腎蒂 renal hilum, renal sinus and renal pedicle腎血管與腎段 blood ve

14、ssels of kidney and renal segment腎被膜 covering membrane of kidney,,,1A.位置: 腎位于脊柱兩側(cè)，腹膜后間隙內(nèi)，屬腹膜外位器官；左腎在第11胸椎體至第2腰椎體之間，右腎在第12胸椎體上緣至第3腰椎體之間。,,,或腎角,腎門在腹后壁的體表投影點(diǎn)：在豎脊肌外緣與第12肋的夾角處，稱腎區(qū)renal region 、脊肋角或腎角renal angle。腎病患者觸壓和扣

15、擊該處可引起疼痛。,,,,,,,,,,2.5cm,7.5~8.5cm,,腎的體表投影,1B.腎的毗鄰 relations of kidney,The right kidney is related to the right lobe of liver, descending part of duodenum, and right colic flexure.The left kidney is related to the stoma

16、ch, spleen, tail of pancreas, coils of jejunum and left colic flexure.,Anteriorly,Superiorly -- the suprarenal gland,,Medially -- the pedicle of kidney, inferior vena cava, abdominal aorta,Posteriorly,The costodiaphragma

17、tic recess The 12th rib，psoas major,quadratus lumborum, transversus abdominis,Posteriorly,The diaphragm The lumbocostal triangleThe subcostal vesselsThe iliohypogastric nerveThe ilioinguinal nerveThe genitofemora

18、lnerveThe psoas majorThe quadratus lumborumThe transversus abdominis,（1）腎門renal hilum：為腎內(nèi)側(cè)緣中部的凹陷處，是腎血管、腎盂、神經(jīng)和淋巴管出入的部位。,2. 腎的結(jié)構(gòu),,,（2）腎竇renal sinus：為腎門向腎內(nèi)延伸，由腎實(shí)質(zhì)圍成的腔隙，內(nèi)有腎小盞minor renal calices、腎大盞major renal calices、腎盂re

19、nal pelvis、腎動脈分支和腎靜脈屬支及淋巴、神經(jīng)和脂肪等。,（3）腎蒂renal pedicle：由出入腎門的腎血管、腎盂、神經(jīng)和淋巴管等所組成。其主要結(jié)構(gòu)的排列，自前向后為腎靜脈、腎動脈和腎盂，由上向下為腎動脈、腎靜脈、腎盂。,3A. 腎的動脈和靜脈,,Posterior segmental a.,Anterior trunk,Posterior trunk,,Superior segmental a.,Superior an

20、terior segmental a.,Inferior anterior segmental a.,Inferior segmental a.,Renal a.,,3B. 腎段動脈與腎段,右腎的前面觀,右腎的后面觀,4B. 腎的淋巴,,4B. 腎的神經(jīng),,（1）腎被膜由外向內(nèi)依次為腎筋膜、脂肪囊、纖維囊。,5. 腎被膜,（2）腎筋膜前、后兩層向下互相分離，并分別與腹膜下組織和髂筋膜移行，其間有輸尿管通過。,（3）腎易向下方游走，稱腎下

21、垂。腎周膿液可沿腎筋膜向下蔓延至髂窩或大腿根部。,（三）輸尿管腹部abdominal part of Ureter,行程 course分部 division 生理性狹窄 physiological stricture毗鄰relations體表投影 surface rejection,左、右輸尿管腹部的毗鄰,,,,,﹡,﹡,,ileum,,,,Duodenojejunal flexure,,Testicular vesse

22、ls,,,,Descending part of duodenum,,,,,腸系膜根部root of mesentery,乙狀結(jié)腸系膜部root of sigmoid mesocolon,輸尿管腹部的體表投影,在腹前壁與半月線相當(dāng)；在腰部約在腰椎橫突尖端的連線上。,,,,,,,輸尿管的動脈,,,,,（三）腎上腺 suprarenal gland,位置 position形態(tài) shape毗鄰 relation動脈 artery

23、靜脈 vein,1．位置:位于腹膜后隙，脊柱的兩側(cè)，平第11胸椎高度，兩腎的上端,屬腹膜外器官，為成對的內(nèi)分泌器官。,2．形態(tài): 左腎上腺呈半月形，右腎上腺呈三角形。,,3. 毗鄰,（1）后面：為膈。（2）兩腎上腺之間：為腹腔叢。（3）前面：左腎上腺前面的上部鄰網(wǎng)膜囊與胃后壁;下部鄰胰尾、脾血管;內(nèi)側(cè)緣鄰腹主動脈。右腎上腺前面為肝,內(nèi)側(cè)緣鄰下腔靜脈。,,,經(jīng)腎上腺橫斷層面,,,,,,經(jīng)腎上腺橫斷層面(T12~L1椎間盤),,,,13

24、.膽囊,24.右腎30.右腎上腺5.尾狀葉23.下腔靜脈7.肝門靜脈9.肝固有動脈17.左腎19.左腎上腺4.脾靜脈16.脾20.腹主動脈,腎上腺的動脈和靜脈,,（四）腹主動脈 abdominal aorta,The celiac trunk(T12) The superior mesenteric a.(L1) The inferior mesenteric a.(L3),The middle suprare

25、nal a. The renal a. (L2) The testicular (ovarian) a.,The inferior phrenic a. The lumbar a. The median sacral a.,The unpaired visceral braches:,Paired visceral branches：,Parietal branches：,（五）下腔靜脈 Inferior Vena Cava,I

26、ts main tributaries are The Hepatic veinThe right suprarenal veinThe renal veinThe right testicular (ovarian) veinThe inferior phrenic veinThe lumbar vein,（七）腰叢 lumbar plexus,（六）腰交感干 lumbar sympathetic trunk,Form

27、ation, location,The iliohypogastric n.The ilioinguinal n.The lateral femoral cutaneous n.The femoral n.The genitofemoral n.The obturator n.The lumbosacral trunk,解剖與觀察Dissection and Observation,Trace and clean the

28、 superior mesenteric artery and its branches.Trace and clean the superior mesenteric vein and its tributaries.,,Trace and clean the inferior pancreatico-duodenal aa.,,解剖闌尾動脈,,,觀察回盲口/瓣、闌尾口,Trace and clean the inferior me

29、senteric artery and its branches.Trace and clean the inferior mesenteric vein and its tributaries.,Trace and Clean the hepatic portal vein and its tributaries.,,Remove the retroperitoneal (pararenal) fat on both sides o

30、f the vertebral column between the level of the T12 to L3 vertebra to expose the anterior layer of the fasica .,,Make a vertical incision through the renal fascia and adipose capsule of kidney to expose the fibrous caps

31、ule and kidney.,,Identify the left and right suprarenal glands.,,Trace and clean the superior, middle and inferior suprarenal arteries.,,Trace and clean the left and right suprarenal veins.,,Open the anterior layer of r

32、enal fascia, and examine the renal adipose capsule. Open the fibrous capsule.Dissect the pedicle of kidney and examine the relationship of the contents. Clean the abdominal part of the ureters.Trace and clean the vis